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State of Nebraska 5/31/2019 3:06:36 PM PAGE 6/012 <br />Fapfip3117 <br />NE Scc of -State - Robert B Evnen <br />Filing Document :Et: 1905001958-8 <br />Debtor Haute 4M CLEANINC.i. ..LC <br />Ilifing Date and Two e 05/31/2019 10 15 AM <br />Pages 1 <br />STATE A 1,4; T.:1EN NERRASK £3f:..PARTrkikliNT Of' E...43301,1 DOL. Cc:stet:if C.:nuns:A <br />P.O. 'Rita 94(.00 <br />1.iiiroit1. NU. 01509-4600 <br />‹AtIt.tDts,..;4 Tettplorte t4f,r2-t 471-991.?. <br />FAX C402)471-9917 <br />Emplet.f.er <br />1.4:thie Verson: 4NI Csiii.I.0 <br />Atittriess: <br />1t)1,1 S:q11.11 1' 1u: tiracitE NE: 6880: <br />NOM. Seri:if No.: <br />N[(L Acet. <br />Tn e id with the Ilt.,,ister tif Deeds in the ft.1lowintt (.tis <br />Federul ED No. I SSA <br />1 <br />1 i 5 aaal tac ptiytteantr t '1 1. 39 1t\ 51 <br />;,61.71 011 53 3+,7,9a1..aa•W. <br />50, pttc et,teal aeel rt.:cc:San act: de: 1tdot tttas ,:coptc..ca dud attradot detttaic; ,etc: st,1,,tte: to IX, OF <br />ii,r13,11t, 0 kn 353. tt, <br />Qtr. Yr, <br />Date Aswssed <br />Com triczed Tax. Or PAyitient n I_ ieu <br />OE Contributions Oise <br />PeritsIty <br />Intert:st <br />Through <br />Suntotol <br />V2ii 1 <br />41:2oltc <br />17 <br />S0.00 S 1062' <br />S Efll <br />' 1 :Q. 64 <br />S 0.00 <br />S 0.011 <br />0.1.30 <br />0.0) <br />0.00 <br />S 00 <br />T(ITA Cr)mhined r1.:•nzent Liti! of Contrib3itim:1 Duc Olitdrr this Ii.51 2.3g.tt <br />..... ....... <br />1 certify that the Nebrmka Department of tabor hn3 tionsplict.i with th Etni.iute.itt Security 14itt, ttf the State of iNehrsts144i in the <br />determination of the 3332051111 clue, the etttplo>.er t,ristin 11di 3'4sd to pay iht: am nnnt Oat af.lrs.!T tiettland. <br />JOHN <br />Commissioner or Labor <br />time Nifty 29, 2019 <br />}.1E'ElitiN FILED Ct)E'll'..S T11: Neti.r. bei)t. rtf - <br />r.c4. Li51 941,00 <br />1.i4.a61, NE, 1:34:3Crt-tt.(4) <br />i S..113 -11E3111' 12, Cent:rat C tionsel <br />itsBY is. 11..1415.1,1, tiepl 3uuns1 <br />JAN ROD S. 11-10117,(1.11,) k`ga (1)1111501 <br />NUM. DEPT. 4.)1; EADOR <br />CDARGE -11:14765 <br />